Frailty care is rarely limited to a single team, service, or episode of care. Effective Comprehensive Geriatric Assessment (CGA) depends on continuity and coordination across neighbourhood systems over time. This article explores how PCN Hubs, Integrated Neighbourhood Teams, and locality-wide frailty services can organise continuous CGA around people living with frailty.
Population health management for frailty is not defined by identification alone, but by delivering the right intervention at the right stage of frailty progression.
Part 5 of the Frailty Paradox series explores frailty management across the spectrum, from prevention and early intervention through to Comprehensive Geriatric Assessment (CGA), continuity, and coordination for people living with moderate and severe frailty.
Not everyone living with frailty can be seen. The question is who is reached in time.
In Part 4 of the Frailty Paradox series, we explore how signals of deterioration are used to prioritise risk and target coordinated care.
Frailty identification in the NHS is often fragmented, inconsistent, and reactive.
In Part 3 of the Frailty Paradox series, we explore how continuous, clinician-led identification through a self-replenishing frailty register can make frailty visible across a population, forming the foundation for effective prioritisation and intervention.
The NHS cannot manage frailty if it cannot see it.
In Part 2 of the Frailty Paradox series, we explore why general practice is best placed to anchor a shared, system-wide view of frailty. We examine the strengths and limitations of current approaches, drawing on real-world experience and published evidence.
The findings suggest that current methods may identify fewer than half of patients living with frailty, and that no single tool meets all four key requirements for effective identification: accuracy, scalability, early detection, and usability in clinical practice.